APPLICATION FOR LICENSED PROFESSIONAL COUNSELOR

Mississippi Board of Examiners for Licensed Professional Counselors

APPLICATION PACKET

For Reference only

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APPLICATION FOR LICENSED PROFESSIONAL COUNSELOR * * * GENERAL INSTRUCTIONS * * *

GENERAL INSTRUCTIONS: Application should be completed by the applicant using the online process. Paper version is for reference. Refer to the Rules & Regulations when completing the Application and Forms. All items in Part I, II, III, IV, V, & VI of Application must be completed and submitted via the online process to the MS

Board of Examiners for Licensed Professional Counselors (Rule 9). Forms must be filled out completely and submitted together in one packet to complete the online application. Note: Form A, B, and/or C, must be properly notarized and signed, placed in a sealed envelope with the supervisor's

signature over the envelope flap and returned to you for inclusion with your application materials. Faxed documents are not acceptable. Applicants must meet all applicable requirements before being considered for licensure. All forms/documents submitted in support of the application must bear original signatures. NAME(S): If some of your records are in different names, please indicate in Part I of application. Provide only requested information. If the Board requires additional information, you will be notified in writing. Applicants are encouraged to make a copy of application materials for their personal records. The Board must receive all the supporting documents required, e.g. color passport style photo, supervision verification

form(s) (Form A, B, and/or C), transcript(s), and background check from the Department of Public Safety (Form E). You are responsible for ensuring that your file is complete. There are no exceptions! The Board only reviews complete applications with all required information and application materials received by the

deadline date. Incomplete applications will not be reviewed by the Board.

CHECKLIST FOR COMPLETE APPLICATION MATERIALS: Online Application for Licensed Professional Counselor (Parts I, II, III, IV, & V, VI) Notarized Supervision Verification Forms o Practicum/Internship Supervision Verification ? Form A (If applicable) o Post-Master's Supervision Verification - Form B (This form has 2 pages.) o Post-Master's Supervision Verification - Missing or Deceased Supervisor Affidavit - Form C (if applicable) Official Transcript(s) from an approved educational institution verifying educational qualifications are to be included with application materials. Only the graduate-level transcripts are required. The official transcript(s) should be sealed in an envelope and signed or stamped across the envelope's seal by the transcript clerk issuing the document to the applicant. If the approved educational institution will not issue an official transcript to the applicant, the approved educational institution may submit the official transcript directly to the Board. If transcript(s) are sent directly to the Board office from the school/university, ask the Registrar to provide you with a verification that the transcript has been sent and include this with your application. Fee Schedule. New Applications: A non-refundable Application Fee of $100. Official NCE or NCMHCE score report, if applicable. The official score report must be submitted directly to the Mississippi LPC Board from the National Board for Certified Counselors, Inc. (NBCC). Completed background check release (Form E) and fee sent directly to Department of Public Safety. Color passport style photo uploaded. Verification of Licensure in Other Jurisdiction (Form D): If you are or have ever been licensed in another State(s), please have that/those State(s) officially certify that license directly to the Board office.

APPLICANT FILE: A file is "open" one year from the date application is received; the applicant must pay a reapplication fee in order to

reactivate their file for one (1) additional year. After two (2) years, incomplete applications will be destroyed.

APPLICATIONS REVIEW: The Board reviews only applications received by the deadline that corresponds to the regularly scheduled meetings (10

days prior to regularly scheduled meeting). Only complete applications received by the corresponding deadline will be reviewed. Individuals approved by the Board as candidates will receive a letter from the Board notifying them of their Candidacy to

sit for the licensure exam, and it is the candidate's responsibility to schedule licensure exam. Individuals approved for licensure will be awarded a license as a professional counselor. The Board meeting dates are posted on the website. lpc.state.ms.us

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DENIED APPLICATIONS (Board Rule 5.1(D)): If your application is denied, you will receive a reason for the denial. Within sixty (60) days of the date of that letter, you

may request an administrative hearing at the next regularly scheduled Board meeting. You should enclose additional evidence [documentation] to support your qualifications, if you wish the Board to reconsider the denial of your application. You may request, in writing, to meet with the Board. If you do, an appointment will be scheduled. If the Board reviews your application again and denies it, an individual can appeal the decision of the Board to the circuit court of the county of the applicant's residence. If you do not petition the Board to re-evaluate your application within the 60-day period, your application file will be closed. Any subsequent request for licensure will require submission of a new application, documents, and the required fee.

REINSTATEMENT (LICENSE LAPSED GREATER THAN One (1) YEAR) (Rule 5.3) You must meet the current licensure requirements, submit a new application, and pay all application and renewal fees.

YOUR COPY: Keep a complete copy of your application materials, except those under seal.

SUBMIT PACKET VIA RETURN RECEIPT TO: MISSISSIPPI BOARD OF EXAMINERS

FOR LICENSED PROFESSIONAL COUNSELORS 239 N. Lamar Street Suite 402 Jackson, MS 39201 601-359-1010

(Return Receipt will provide you with assurance/proof materials are received by Board office.)

Although the Mississippi LPC Board's licensure process requires that an applicant receive Mississippi LPC Board approval to sit for the National Counselor Examination (NCE) or the National Clinical Mental Health Counselor Exam (NCMHCE), there are two specific situations in which an applicant may have already taken the NCE or the NCMHCE outside of the Mississippi LPC Board licensure process: Individuals holding the National Certified Counselor (NCC) credential may have already taken the NCE or those licensed in another jurisdiction may have already taken the NCE or the NCMHCE. If you have already taken the NCE or the NCMHCE in either of these two situations, you have one additional requirement. IN ADDITION TO THE MATERIALS LISTED ABOVE, YOU MUST ALSO SUBMIT: ? An official copy of your passing scores. (Your licensure application is considered incomplete without submission of the test scores and will not be forwarded to the Mississippi LPC Board for review until an official copy of your passing scores is received by the Board Office. Therefore, if you have already taken the NCE or the NCMHCE, you should contact the National Board for Certified Counselors, Inc., (NBCC) and request that your test scores be submitted directly to the Mississippi LPC Board. It is your responsibility to ensure that the Mississippi LPC Board receives an official copy of your passing test scores.)

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APPLICATION FOR MISSISSIPPI LICENSED PROFESSIONAL COUNSELOR

ATTACH PHOTO HERE

I hereby make application for Licensed Professional Counselor pursuant with the laws of the State of Mississippi and the Rules and Regulations for The Mississippi State Board of Examiners for Licensed Professional Counselors.

NO FAXED FORMS ACCEPTED

(check one)

APPLY FOR LICENSURE: If you meet all licensure requirements and have taken and passed the NBCC Examination and completed your Supervised Experience in accordance with the Rules and Regulations, complete Parts I, II, III, IV, V, and VI of the Application, request an official passing grade letter from NBCC to the Board office, if it is not already on file, and submit all required supporting documents as detailed in General Instructions.

APPLY FOR LICENSURE CANDIDACY: If you meet licensure requirements in effect at the time the application is received by the Board office and intend to take the license examination, if approved, complete Parts I, II, III, IV, V, and VI of the Application and submit all required supporting documents as detailed in General Instructions.

Do you require special accommodations for License exam? No Yes (Please provide documentation with application.)

COMITY: If you currently hold a LPC license in another state with at least five (5) years of professional work experience as a counselor since the date of initial licensure, that licensure was maintained continuously during those five (5) years and that no substantiated complaints or disciplinary action(s) have ever been taken against the licensee. Submit a Curriculum Vitae (C.V.), three (3) work references, and Verification of Licensure in Other Jurisdiction along with certified copies of the contents of licensure file sent directly to the Board's office.

Are you a member of the military, veteran, or spouse of active duty military? No Yes (Please provide documentation.)

PART I - PERSONAL INFORMATION

Please type or print clearly.

Mr.

Name

Ms.

Dr.

(Type or Print legal name as it should appear on certificate)

Name(s) as shown on transcripts and/or exam records if different from above:

___________________________________________________________________________________________________

If granted a license, your name, preferred address, preferred phone number, email address, and license number will appear on the internet. You must immediately notify the Board in writing of any changes of information.

PREFERRED ADDRESS: HOME BUSINESS

HOME ADDRESS: ____________________________________________________________________________________

Street (**P.O. Box not acceptable) Cit

y

State

Zip

Code

BUSINESS ADDRESS: ________________________________________________________________________________

Street Cit

y

State

Z

ip Code

PREFERRED PHONE NUMBER: HOME BUSINESS CELL HOME PHONE: (___)_________________ BUSINESS PHONE: (___)_________________ CELL: ( _)_______________

EMAIL ADDRESS: ___________________________________________________________________________________

DATE OF BIRTH: _____________________ SOCIAL SECURITY NUMBER _____________________________

Month/Day/Year

NATIONAL COUNSELOR EXAMINATION (NCE) TAKEN: Yes

No If "Yes," Date Taken _____________________

Indicate Pass/Fail

Pass Fail

If "Pass," Score _________/_________ (your score / minimum score)

NATIONAL CLINICAL MENTAL HEALTH COUNSELOR EXAM (NCMHCE) TAKEN: Yes

No

If "Yes," Date Taken _______________ Indicate Pass/Fail

Pass Fail If "Pass," Score _________________

Have you requested passing scores be forwarded to the Board

Yes No

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PART I cont'd

Board Office Use Only Date Received __________ Fee Paid ___________

INSTRUCTIONS:

Complete this part for the graduate degree that you want the Board to consider as part of this application.

The official transcript(s) should be sealed in an envelope and signed or stamped across the envelope's seal by the

transcript clerk issuing the document to the applicant. If the approved educational institution will not issue an official

transcript to the applicant, the approved educational institution may submit the official transcript directly to the

Board. If transcript(s) are sent directly to the Board office from the school/university, ask the Registrar to provide

you with a verification that the transcript has been sent and include this with your application.

DEGREE:

Ph.D.

Date Awarded:

Program/Major:

Name of Institution:

Street Address:

City/State/Zip:

Specialist

Master's

Other _________________

DEGREE:

Ph.D.

Date Awarded:

Program/Major:

Name of Institution:

Street Address:

City/State/Zip:

Specialist

Master's

Other __________________

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PART II ? COURSE VERIFICATION FORM

Applicant's Name_______________________________________________________________________________

Complete the following according to your graduate work.

A graduate program related to counselor education is defined as one that contains course work in all of the following areas. Each applicant must have completed a three (3) hour semester course or its equivalent in each of the following areas.

Please note that all references to hours of college credit are for semester hours. Quarter hours may be converted to semester using the standard formula (Number of quarter hours X .66 = Semester hour equivalent). Semester hours must total sixty (60) hours.

Area Human Growth and 1 Development

Course Number

Course Title

University/College

Social and Cultural 2 Foundations

Counseling and 3 Psychotherapy Skills

Group Counseling 4

Lifestyle and Career 5 Development

Testing and Appraisal 6

Research and Evaluation 7

Professional Orientation 8 to Counseling or Ethics

Theories of Counseling 9 Psychotherapy and

Personality Marriage and/or Family 10 Counseling/Therapy

Abnormal Psychology 11 and Psychopathology

Internship 12

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PART III - SUPERVISED EXPERIENCE

INSTRUCTIONS:

List only the name(s) and address(es) of the Supervisor(s) whose time you will use to fulfill the Supervision requirement for licensure and will complete Supervision Verification Forms on your behalf. Have each Supervisor complete a separate "Supervisor Verification Form." (Form A or Form B) If your Supervisor is missing or deceased, complete Form C. Effective July 1, 2015, Applicants shall present post-masters' supervised experience obtained within the last seven years.

SUPERVISORS

NAME: __________________________________________________________________________________________________

ADDRESS: _______________________________________________________________________________________________

Street

City

State

Zip

Place of employment where Supervisory Hours were obtained ______________________________________________

Date of Supervised experience: FROM ________________ TO ________________ BQS: NO YES, DATE BQS APPROVED: _____________

TOTAL HOURS: ______ DIRECT CONTACT: ______ INDIVIDUAL SUPERVISION: ______ GROUP SUPERVISION: ______

Did you receive at least one (1) face-to-face supervision hour for every forty (40) hours of services provided OR one (1) face-to-face hour of supervision for every twenty-five (25) hours of Direct Services? ______

At the time of supervision my experience/employment was (check only one)

PRACTICUM

INTERNSHIP

POST DEGREE ___ FULL TIME ___ PART TIME AT _________ %

NAME: _________________________________________________________________________________________

ADDRESS: ______________________________________________________________________________________

Street

City

State

Zip

Place of employment where Supervisory Hours were obtained ____________________________________

Date of Supervised experience: FROM ______________________ TO ________________________ BQS: NO YES, DATE BQS APPROVED: _____________

TOTAL HOURS: ______ DIRECT CONTACT: ______ INDIVIDUAL SUPERVISION: ______ GROUP SUPERVISION: ______

Did you receive at least one (1) face-to-face supervision hour for every forty (40) hours of services provided OR one (1) face-to-face hour of supervision for every twenty-five (25) hours of Direct Services? ______

At the time of supervision my experience/employment was (check only one)

PRACTICUM

INTERNSHIP

POST DEGREE ___ FULL TIME ___ PART TIME AT _________ %

NAME: ________________________________________________________________________________

ADDRESS: ____________________________________________________________________________

Street

City

State

Zip

Place of employment where Supervisory Hours were obtained ____________________________________

Date of Supervised experience: FROM ______________________ TO ________________________ BQS: NO YES, DATE BQS APPROVED: _____________

TOTAL HOURS: ______ DIRECT CONTACT: ______ INDIVIDUAL SUPERVISION: ______ GROUP SUPERVISION: ______

Did you receive at least one (1) face-to-face supervision hour for every forty (40) hours of services provided OR one (1) face-to-face hour of supervision for every twenty-five (25) hours of Direct Services? ______

At the time of supervision my experience/employment was (check only one)

PRACTICUM

INTERNSHIP

POST DEGREE ___ FULL TIME ___ PART TIME AT _________ %

NAME: ________________________________________________________________________________

ADDRESS: ____________________________________________________________________________

Street

City

State

Zip

Place of employment where Supervisory Hours were obtained ____________________________________

Date of Supervised experience: FROM ______________________ TO ________________________ BQS: NO YES, DATE BQS APPROVED: _____________

TOTAL HOURS: ______ DIRECT CONTACT: ______ INDIVIDUAL SUPERVISION: ______ GROUP SUPERVISION: ______

Did you receive at least one (1) face-to-face supervision hour for every forty (40) hours of services provided OR one (1) face-to-face hour of supervision for every twenty-five (25) hours of Direct Services? ______

At the time of supervision my experience/employment was (check only one)

PRACTICUM

INTERNSHIP

POST DEGREE ___ FULL TIME ___ PART TIME AT _________ %

1

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PART IV - PERSONAL AND LICENSURE HISTORY

ALL OF THE FOLLOWING QUESTIONS MUST BE ANSWERED. If you answer "Yes" to ANY of the following questions, explain in full by addendum to the application. You must make a statement that includes, but is not limited to, the date(s) location(s), specific circumstances, practitioners and/or treatment involved, and must be substantiated by official documents sent directly to the board office from the respective state licensing board or official copies of court records. A "yes" answer is NOT an automatic cause for denial of licensure. The failure to accurately disclose information will result in immediately denial of licensure.

Yes No Yes No

1. Do you currently have a medical condition which in any way impairs or limits your ability to practice professional counseling with reasonable skill and safety? a. If yes, are they reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring program?

Yes No Yes No

2. Do you currently use chemical substances? a. If yes, do they in any way impair or limit your ability to practice professional counseling with reasonable skill and safety?

Yes No 3. Are you currently engaged in the illegal use of controlled substances?

Yes No

4. Have you ever had an application for a license to practice professional counseling in any state, country, or province, denied, reprimanded, suspended, restricted, revoked, otherwise disciplined, curtailed, or voluntarily surrendered under threat of investigation or disciplinary action?

Yes No

5. Have you ever had a license or certificate in any mental/health care profession, reprimanded, suspended, restricted, revoked, otherwise disciplined, curtailed, or that You voluntarily surrendered under threat of investigation or disciplinary action?

Yes No Yes No Yes No

6. In relation to the performance of your professional services in counseling or any profession: a. Have you ever had a final judgment rendered against you; b. Have you ever had settlement of any legal action rendered against you; or c. Are there any legal actions pending against you or to which you are a party?

Yes No 7. Have you ever been rejected or censured by a professional association?

Yes No

8. Is there currently pending, in any jurisdiction, a complaint against your professional conduct of competency in counseling or any profession?

Yes No

9. Are you now or have you ever been a defendant in civil litigation in which the basis of the complaint against you was alleged negligence, malpractice or lack of professional competence?

Yes No

10. Have you EVER been found guilty after trial, or pleaded guilty, no contest, or nolo contendre to a crime (felony or misdemeanor) in any court, excluding

minor traffic violations? Driving under the influence or driving while impaired is not a minor traffic offense for purposes of this question.

Yes No 11. Have you ever been convicted of any criminal offense?

Yes No 12. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, or voyeurism?

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